Injury Report Template: OSHA Fields, Details & Signatures

Injury Report Template

[Organization / Employer / School / Program Name]

[Address]

[City, State/Province, ZIP/Postal Code]

Phone: [Phone Number]

Email: [Email Address]

1. Injured Person Information

Full Name: [First, Middle, Last]

Date of Birth: [MM/DD/YYYY]

Age: [Age]

Gender: [Gender]

Role (check or describe):

• Employee

• Student / Child

• Athlete / Participant

• Visitor / Customer

• Contractor / Vendor

• Other: [Describe]

Employee

Student / Child

Athlete / Participant

Visitor / Customer

Contractor / Vendor

Other: [Describe]

Home Address:

[Street Address]

[City, State/Province, ZIP/Postal Code]

Phone Number: [Phone Number]

Email Address: [Email Address]

2. Incident Date, Time, and Location

Incident Date: [MM/DD/YYYY]

Incident Time: [HH:MM a.m./p.m.]

Location of Incident (room, area, field, worksite, street, etc.): [Location]

Type of Setting (check one):

• Workplace

• School / Childcare

• Sports / Recreation

• Public place / Business

• Roadway / Vehicle / DUI-Related

• Home / Residential

• Other: [Describe]

Workplace

School / Childcare

Sports / Recreation

Public place / Business

Roadway / Vehicle / DUI-Related

Home / Residential

3. Activity at the Time of Injury

Describe what the injured person was doing at the time of the incident (be specific):

[Example: “Lifting boxes onto a shelf,” “Running during PE class,” “Walking through hallway,” “Driving northbound on [Street],” “Playing in a soccer match.”]

Was this a normal / expected activity for this setting?

• Yes

• No – explain: [Brief explanation]

Yes

No – explain: [Brief explanation]

4. Description of Incident

Provide a clear, factual description of how the incident occurred. Avoid opinions or assigning blame; focus on what happened.

Description of Incident:

[Free-text narrative. Suggested points to cover:]

• What was happening immediately before the incident.

• How the injury occurred (slip, trip, fall, struck by object, collision, sudden movement, etc.).

• Surfaces, equipment, vehicles, or substances involved (wet floor, steps, machinery, another vehicle, ball, etc.).

• How the injured person landed, was struck, twisted, or otherwise hurt.

What was happening immediately before the incident.

How the injury occurred (slip, trip, fall, struck by object, collision, sudden movement, etc.).

Surfaces, equipment, vehicles, or substances involved (wet floor, steps, machinery, another vehicle, ball, etc.).

How the injured person landed, was struck, twisted, or otherwise hurt.

5. Injury Details

Body Part(s) Injured (check or describe):

• Head / Scalp

• Face / Eye / Nose / Mouth

• Neck

• Shoulder / Arm / Elbow / Wrist / Hand

• Chest / Ribs

• Back / Spine

• Hip / Thigh

• Knee / Lower Leg

• Ankle / Foot / Toes

• Multiple areas

• Other: [Describe]

Head / Scalp

Face / Eye / Nose / Mouth

Neck

Shoulder / Arm / Elbow / Wrist / Hand

Chest / Ribs

Back / Spine

Hip / Thigh

Knee / Lower Leg

Ankle / Foot / Toes

Multiple areas

Side of Body: [Left / Right / Both / Center / Unknown]

Type of Injury (check all that apply):

• Bruise / Contusion

• Cut / Laceration / Scratch

• Abrasion / Graze

• Sprain / Strain

• Suspected Fracture / Dislocation

• Burn (thermal / chemical / electrical)

• Bite / Sting

• Concussion / Head Impact (suspected)

• Other: [Describe]

Bruise / Contusion

Cut / Laceration / Scratch

Abrasion / Graze

Sprain / Strain

Suspected Fracture / Dislocation

Burn (thermal / chemical / electrical)

Bite / Sting

Concussion / Head Impact (suspected)

Visible Signs of Injury:

[Example: redness, swelling, bleeding, deformity, limited movement, discoloration.]

6. Symptoms and Pain

Injured Person’s Reported Symptoms (use their own words where possible):

[Free-text, e.g., “sharp pain in right ankle when walking,” “headache,” “dizziness,” “nausea,” “numbness in fingers.”]

Pain Level (0–10 scale; 0 = no pain, 10 = worst pain imaginable):

Reported Pain Score: [0–10]

Other Observed Signs (check or describe):

• Dizziness / unsteady gait

• Confusion / disorientation

• Difficulty speaking or responding

• Shortness of breath

• Pale / sweaty / clammy skin

• Loss of consciousness (approximate duration: [Time])

• Vomiting

• Other: [Describe]

Dizziness / unsteady gait

Confusion / disorientation

Difficulty speaking or responding

Shortness of breath

Pale / sweaty / clammy skin

Loss of consciousness (approximate duration: [Time])

Vomiting

7. Immediate Response and Treatment

Did the injured person stop activity immediately?

Person(s) Providing First Aid or Initial Response:

Name(s) and Role(s): [List]

Care Provided On-Site (check all that apply):

• Area cleaned

• Bandage / dressing applied

• Ice pack / cold compress

• Pressure applied to control bleeding

• Immobilization (splint, sling, brace)

• Elevation of injured area

• Rest and observation in designated area

• CPR or emergency life support (briefly describe)

• Other: [Describe]

Area cleaned

Bandage / dressing applied

Ice pack / cold compress

Pressure applied to control bleeding

Immobilization (splint, sling, brace)

Elevation of injured area

Rest and observation in designated area

CPR or emergency life support (briefly describe)

Was 911 / Emergency Medical Services called?

• Yes

• No

No

If Yes:

• Time Called: [HH:MM a.m./p.m.]

• Responding Agency: [Name]

• Transported to Medical Facility? [Yes / No]

• Facility Name: [Hospital / Clinic Name]

Time Called: [HH:MM a.m./p.m.]

Responding Agency: [Name]

Transported to Medical Facility? [Yes / No]

Facility Name: [Hospital / Clinic Name]

8. Medical Evaluation and Work/School Status

Did the injured person receive or seek medical evaluation after leaving the scene?

• Yes

• No

• Unknown at time of report

Unknown at time of report

If Yes, specify:

• Facility / Provider Name: [Name]

• Type of Facility: [ER / Urgent Care / Clinic / Personal Doctor / Other]

• Date of Visit: [MM/DD/YYYY]

Facility / Provider Name: [Name]

Type of Facility: [ER / Urgent Care / Clinic / Personal Doctor / Other]

Date of Visit: [MM/DD/YYYY]

Has a doctor or medical provider given written work, school, or activity restrictions?

• Yes – describe: [e.g., “No sports for 2 weeks,” “No lifting over 10 lbs,” “Seated work only.”]

• No

• Unknown

Yes – describe: [e.g., “No sports for 2 weeks,” “No lifting over 10 lbs,” “Seated work only.”]

Unknown

Work / School Status Immediately After Incident:

• Returned to normal duties / activities

• Returned with temporary restrictions

• Sent home

• Transported for medical care

• Other: [Describe]

Returned to normal duties / activities

Returned with temporary restrictions

Sent home

Transported for medical care

9. Witness Information

Were there any witnesses to the incident?

• Yes

• No

• Unknown

Witness 1:

Full Name: [Name]

Role (employee, student, customer, etc.): [Role]

Phone / Email (if needed): [Contact]

Brief Witness Statement (summary of what was seen or heard):

[Free-text summary]

Witness 2:

Full Name: [Name]

Role: [Role]

Phone / Email: [Contact]

Brief Witness Statement:

[Free-text summary]

[Add additional witness sections as needed.]

10. Notifications

Person(s) Notified (check and complete):

• Parent / Guardian

• Supervisor / Manager

• HR / Safety Department

• School / Program Administrator

• Property Owner / Landlord

• Other: [Describe]

Parent / Guardian

Supervisor / Manager

HR / Safety Department

School / Program Administrator

Property Owner / Landlord

Details:

Name of Person Notified: [Name]

Role / Relationship: [Role]

Method of Notification: [In person / Phone / Voicemail / Email / Other]

Date and Time of Notification: [MM/DD/YYYY – HH:MM a.m./p.m.]

Summary of What Was Communicated:

[Free-text summary]

11. Follow-Up and Corrective Actions

Planned or Completed Follow-Up Actions (check or describe):

• Monitor injured person’s condition at subsequent visits / shifts.

• Request medical documentation or work status note.

• Inspect area, equipment, or conditions involved.

• Repair, clean, or modify equipment or environment.

• Provide refresher training or safety reminder.

• Update internal policies or procedures.

• Other: [Describe]

Monitor injured person’s condition at subsequent visits / shifts.

Request medical documentation or work status note.

Inspect area, equipment, or conditions involved.

Repair, clean, or modify equipment or environment.

Provide refresher training or safety reminder.

Update internal policies or procedures.

Person Responsible for Follow-Up: [Name and Title]

Target Date for Completion: [MM/DD/YYYY]

12. Signatures

Reporting Person

I certify that this Injury Report reflects my understanding of the incident and information available at the time of completion.

Name: [Reporting Person Full Name]

Position / Role: [Title / Relationship]

Signature: ___________________________

Date: [MM/DD/YYYY]

Supervisor / Administrator Review (if applicable)

I have reviewed this report and will ensure that appropriate follow-up and safety actions are considered and, where approved, implemented.

Name: [Supervisor / Administrator Name]

Title: [Title]

Injured Person / Parent / Guardian Acknowledgment (if required)

I acknowledge that I have been informed of the contents of this Injury Report. This acknowledgment does not indicate agreement with any conclusions and is not a waiver of any rights.

Name: [Injured Person / Parent / Guardian]

Signature: ___________________________

Date: [MM/DD/YYYY]

13. Additional Notes or Attachments

Additional Notes:

[Free-text area for any other relevant information not covered above.]

Attachments (check if included):

• Photos of injury or scene

• Separate incident / accident investigation report

• Medical note or discharge summary

• Internal safety or HR forms

• Other: [Describe]

Photos of injury or scene

Separate incident / accident investigation report

Medical note or discharge summary

Internal safety or HR forms